The novel coronavirus pandemic (COVID‐19), which began in late 2019, has affected all aspects of our everyday life. The medical ecosystem has changed profoundly, at times stretching its capacity, to provide proper healthcare to all those in need.

Recent investigations have focused on the impact of the virus on the emergency departments and intensive care units. However, outpatient care has also been fundamentally transformed since the pandemic. There is no consensus on the best way to manage patients with severe pain during the COVID‐19 pandemic. Multiple guidelines have been developed regarding staffing, mitigation of risk, increased utilisation of telemedicine and increased opioid prescribing. Recent publication also demonstrated the altered practice and marked reduction patterns of interventional pain physicians in the United States (Joyce et al., 2020).

A new aspect of this pandemic regards the impact of the newly developed vaccines on patient care, which is of particular relevance due to the recent implementation of mass vaccination programmes all over the world.

A substantial percentage of patients treated in pain management units is elderly, often with systemic comorbidities and hence, according to the epidemiological data, fall into an increased risk group for severe illness (Evidence used to update the list of underlying medical conditions that increase a person’s risk of severe illness from COVID‐19).

Therefore, is it to be expected that a large part of the population reaching pain management units will have been vaccinated or soon‐to‐be vaccinated. Taking into consideration, the huge amount of neuro‐axial corticosteroid injections carried out annually (50,000/year in Israel only), there is a clear need to carefully evaluate the procedures and requirements involved in these injections.

Corticosteroid Injections (CSI) are a key treatment for a wide range of musculoskeletal and degenerative conditions. When injected either to the spinal epidural space or in an intra‐articular manner, CSIs are widely considered good practice for diagnostic and therapeutic purposes prior to committing to orthopaedic surgery.

CSIs have systemic effects, two of which are systemic immune depression (both the innate and adaptive responses) and HPA‐axis depression (Miller et al., 2020). These systemic effects raise concerns regarding COVID‐19 patients and those receiving the vaccination. As such, at the early stages of the pandemic, guidelines were published advising against the use of CSIs. However, more recent investigations suggest that CSIs are most likely a viable treatment for most of the low‐risk patients (McKean et al., 2020). A study of image‐guided CSIs for pain management performed during the initial lockdown period of the COVID‐19 pandemic suggested that these injections were not associated with a higher infection rate than the general population (Chang et al.,). In fact, CSI may be of even greater use given the restricted access to other medical services and elective surgical options during the current crisis.

A similar analysis is required regarding the interaction between CSIs and the newly developed COVID‐19 vaccine. Studies suggest that in immune‐suppressed individuals, the humoral immune response may be compromised, causing a decreased immune response to vaccination. A large US‐based study concluded that patients who received the influenza vaccination and underwent joint CSI before or during the influenza season had a higher relative risk ratio (Sytsma et al., 2018).

In order to manage the risks of the interaction between the steroids and the vaccine, a new set of guidelines was recently developed within our Pain Institute. First, patients are warned of the immunosuppression risks of CSIs and are advised not to receive steroid injections during the 5‐week period beginning 1‐week prior to the first dose of the vaccine until 1‐week after the second dose. Second, in the cases where the patient, after being informed about the risks, insists on receiving an injection, dexamethasone is used. Dexamethasone has been shown to have a shorter duration of systemic effect and is, therefore, favoured over other steroids in these circumstances.

We believe that these guidelines provide sound advice to physicians performing CSIs as part of their treatment plan and are highly relevant as a worldwide effort to mass vaccinate come into effect.

新的冠状病毒大流行（COVID‐19）始于2019年底，已经影响到我们日常生活的方方面面。医疗生态系统已经发生了深刻的变化，有时会扩展其能力，以便为所有有需要的人提供适当的医疗保健。

最近的调查集中在该病毒对急诊科和重症监护室的影响上。然而，自大流行以来，门诊护理也已从根本上改变了。目前尚无关于在COVID-19大流行期间治疗严重疼痛患者的最佳方法的共识。关于人员配备，减轻风险，增加远程医疗利用率和增加阿片类药物处方，已经制定了多个指南。最近的出版物还证明了在美国，干预性疼痛医生的做法有所改变，并且明显减少了疼痛的模式（Joyce等人，  2020年）。

大流行的一个新方面是关于新开发的疫苗对患者护理的影响，由于最近在全球范围内实施了大规模疫苗接种计划，因此这一点特别重要。

在疼痛管理部门接受治疗的患者中，很大一部分是老年人，通常患有系统性合并症，因此，根据流行病学数据，患者属于严重疾病的高风险人群（用于更新可增加人的基础疾病状况的证据）。因COVID- 19导致严重疾病的风险）。

因此，可以预见的是，到达疼痛管理部门的大部分人口将已经接种疫苗或即将接种疫苗。考虑到每年进行大量的神经轴皮质类固醇注射（仅以色列每年50,000次），显然需要仔细评估这些注射所涉及的程序和要求。

皮质类固醇注射剂（CSI）是广泛的肌肉骨骼和退行性疾病的关键治疗方法。当将CSIs注射到脊膜硬膜外腔或以关节内方式注射时，在进行整形外科手术之前，CSI被广泛认为是用于诊断和治疗目的的良好实践。

CSI具有系统性作用，其中两种是系统性免疫抑制（先天性和适应性反应）和HPA轴抑制（Miller等人，  2020年）。这些全身效应引起了对COVID-19患者和接受疫苗接种者的关注。因此，在大流行的早期阶段，发布了指导方针，建议不要使用CSI。但是，最近的研究表明，对于大多数低风险患者，CSIs最有可能是一种可行的治疗方法（McKean等，  2020）。一项在COVID-19大流行初期锁定期进行的影像引导CSI治疗疼痛的研究表明，这些注射并没有比普通人群更高的感染率（Chang等人，）。实际上，鉴于在当前危机期间获得其他医疗服务和选择性外科手术选择的机会有限，CSI可能会发挥更大的作用。

对于CSI与新开发的COVID-19疫苗之间的相互作用也需要进行类似的分析。研究表明，在免疫抑制的个体中，体液免疫反应可能会受到损害，从而导致接种疫苗的免疫反应降低。一项基于美国的大型研究得出的结论是，在流感季节之前或期间接受流感疫苗接种并接受联合CSI的患者具有较高的相对风险比（Sytsma等，  2018）。

为了控制类固醇与疫苗相互作用的风险，最近在我们的疼痛研究所内部制定了一套新的指南。首先，应警告患者CSIs的免疫抑制风险，并建议在从第一次注射疫苗开始1周开始的5周内，直到第二次注射之后1周内不要接受类固醇注射。其次，在患者被告知危险后坚持要注射的情况下，使用地塞米松。地塞米松已被证明具有更短的全身作用持续时间，因此在这些情况下优于其他类固醇。

我们认为，这些指南为执行CSI的医生提供了合理的建议，并将其作为治疗计划的一部分，并且随着全球范围内大规模接种疫苗的努力开始生效，这些指南也具有很高的相关性。